antidepressant effects when used as an an- esthetic agent, 1–3 this vignette recounts a case in which significantly uncomfortable psychiatric complaints followed the use of ketamine during ECT. Although little is known about the psychological effects of ketamine during ECT, one study group recorded several patients experiencing fear and hallucinations upon awakening from ketamine anesthesia compared with none who received propofol. 4 Perceptual distor- tions also have been documented during ketamine infusions. 4 Therefore, always screen for such feelings after ECT, when- ever ketamine is used as an anesthetic agent. Without concern for such perceptual experiences, some people needing ECT might prematurely drop out of treatment, as noted in this vignette. This patient was on interferon B ther- apy before starting the partial hospital pro- gram, and it was discontinued before ECT administration. She reported that her de- pressive symptoms were not affected by interferon and also noticed no changes when it was discontinued. Thus, in this one case, it seemed unlikely that inter- feron or its discontinuation had much im- pact on her depression. Our patient reported increased dis- tress after ECT number 2, even before she ever had ketamine exposure. Since she was “extremely anxious” before receiving ketamine, it is unclear as to whether keta- mine actually did or did not contribute to her perceptual distortions. On 2 occa- sions, she denied any such distortions be- fore receiving ketamine. Before receiving ECT, she denied perceptual concerns, but ketamine in the ECT procedures might have caused her to be upset by inducing dissociative symptoms. Although a few studies have sug- gested a potential benefit of ketamine as having antidepressant effects when ad- ministered as an anesthetic agent, 1–3 it is important to recognize that methohexital has been the standard anesthetic medica- tion during ECT for many decades. Over that prolonged period, it is widely accepted as having been proven to be safe and ef- fective. Therefore, whenever ketamine is considered, note that potentially terrifying adverse effects can follow its use. There should always be a powerful rea- son for prescribing a newer and possibly more dangerous drug than for administering an agent widely demonstrated for decades to be safe and efficacious. Application of a relatively new pharmaceutical, however, is clearly warranted only when an es- tablished medicine is not effective or toler- ated and there is evidence to document clinical efficacy with the newer drug. De- spite antidepressant actions induced by ketamine, methohexital remains the usual drug of choice in pre-ECT applications. Jae Lee, DO Hennepin-Regions Psychiatry Program Minneapolis-St. Paul, MN Puneet Narang, MD Regions Hospital Minneapolis-St. Paul, MN Steven Lippmann, MD University of Louisville School of Medicine Louisville, KY 40202 sblipp01@louisville.edu The authors have no conflicts of inter- est or financial disclosures to report. REFERENCES 1. Kranaster L, Kammerer-Ciernioch J, Hoyer C, et al. Clinically favourable effects of ketamine as an anesthetic agent for electroconvulsive therapy; a retrospective study. Eur Arch Psychiatry Clin Neurosci. 2011;261:575–582. 2. Okamoto N, Tetsuji N. Rapid antidepressant effect of ketamine anesthesia during electroconvulsive therapy of treatment-resistant depression. J ECT . 2010;26:223–227. 3. Abdallah C, Fascula M, Kelmendi B, et al. The rapid antidepressant effects of ketamine in the electroconvulsive therapy setting. J ECT . 2012;28:157–161. 4. Pomarol-Clotet E, Honey G, Murray G. Psychological effects of ketamine in healthy volunteers; phenomenological study. Br J Psychiatry . 2006;189:173–179. Remission of Treatment-Resistant Depression With Electroconvulsive Therapy and Ketamine To the Editor: E lectroconvulsive therapy (ECT) is a highly efficacious treatment for treatment- resistant depression. However, some pa- tients do not or just poorly respond. As ECT has a high success rate, limited evi- dence is available for standard practice or augmentation strategies for ECT-resistant patients. We present a case of ECT-resistant depression that responded by using keta- mine for anesthesia induction. A 75-year- old woman was hospitalized owing to a severe major depressive episode with psy- chotic features, already lasting almost a year. The patient experienced low mood, psychomotor retardation, decreased ap- petite and energy, hopelessness, para- noid and somatic delusions, and suicidal ideation. During her life, she already had at least 5 depressive episodes, with the first one at the age of 21 years. Previously, she had been adequately treated with courses of several tricyclic antidepressants, without clinical improve- ment but with substantially impairing adverse effects. Addition of several antipsy- chotics (haloperidol, olanzapine, risperidone, flupentixol, and pipamperone) had no ef- fect. Given the serious physical and men- tal deterioration, ECT was started. Routine examinations before the start of ECT (ie, blood examination, electroencephalo- gram, and computed tomographic scan of the head) did not reveal any relevant abnormalities. The patient scored 34 on the Hamilton Depression Rating Scale (HDRS), indicating severe depression, and 9 on the Bush-Francis Catatonia Rat- ing Scale (with a score of 3 for mutism, stupor, and withdrawal). Her score on the Mini Mental State Examination (MMSE) was 28/30. At the start of the ECT treatment, the patient took amitriptyline, 25 mg daily; lorazepam, 1 mg daily; and pipamperone, 60 mg daily. After the second ECT, owing to persisting agitation and suicidal idea- tion, clozapine was started and titrated up to 150 mg. As neither lorazepam nor pipamperone had any positive effect, both were discontinued. During the ECT course, amitriptyline was increased to 50 mg and aripiprazole, 10 mg, was added. From session 17, the medication scheme was unchanged. Initially, bifrontal electrode placement was chosen at a frequency of 2 stim- ulations per week. A constant-current Thymatron System IV device (Somatics LLC, Lake Bluff, Ill) was used. Induc- tion and modification were achieved with propofol, 80 mg (1.5 mg/kg), and succi- nylcholine, 25 mg (0.5 mg/kg), before each treatment. Dosing was age based and stimulus parameters were energy, 35%; pulse width, 0.5 milliseconds (ms); frequency, 30 Hz; and stimulus duration, 6.52 seconds. Adequate seizures were obtained ranging from 44 to 55 seconds. As no clinical improvement occurred after 8 sessions, propofol was switched to etomidate (20 mg, 0.4 mg/kg), and bitemporal stimulation was started with stimulus parameters ranging between 35% and 40% energy (pulse width, 0.5 ms; fre- quency, 30 Hz; and stimulus duration, 6.52–7.45 seconds), without any improve- ment after 10 sessions. Owing to cognitive adverse effects, bitemporal electrode place- ment was switched back to bifrontal place- ment at the 19th session, and racemic ketamine was used for induction (40 mg, 0.7 mg/kg), resulting in adequate seizures. After 4 sessions, a spectacular improvement was observed, with a decrease of HDRS Journal of ECT • Volume 30, Number 3, September 2014 Letters to the Editor © 2014 Lippincott Williams & Wilkins www.ectjournal.com e31 Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.